Neonatal Jaundice for Infants ≥ 35 Weeks Gestational Age v4.1 Approval & Citation Explanation of Evidence Ratings Summary of Version Changes PHASE I (E.D.) Pathophysiology Inclusion Criteria Initial Assessment · Previously healthy · Clinical History / Physical Exam Risk for Kernicterus · Age ≤ 14 days · Blood Glucose only if symptomatic v · Born at ≥ 35 wks gestational age · Total Serum Bilirubin with conjugated fraction (use Heelstick sample) · Send G-6-PD screen if patient is male and is from an ethnic region at risk for the Exclusion Criteria disease (Afro-Caribbean, West Africa, India, Pakistan, Bangladesh, East African Asian, Cyprus, Middle East (Iran, Lebanon), China, Italy. · Direct hyperbilirubinemia · Initiate ED Hyperbilirubinemia (Neonatal) Orders · Meets NICU Direct Admit Criteria · Start phototherapy while awaiting results if clinically indicated v · TSB > 5mg/dL above exchange · Determine exchange transfusion threshold using AAP nomogram transfusion threshold · Determine phototherapy threshold using BBiilliiTTooooll™™ or AAP nomogram ! · Signs of acute bilirubin · Web Link to BBiliilTiTooool™l™ IV Fluids NOT encephalopathy routinely indicated · Suspected sepsis or Place PIV only if patient meets ill-appearing NICU Admission Criteria or NICU Consult Criteria v Automatic NICU Admission Criteria Evaluate for Discharge Evaluate for NICU Consult Criteria Evaluate for Inpatient Admission · Signs of acute bilirubin encephalopathy · TSB below phototherapy threshold · TSB within 2mg/dL of exchange · TSB above phototherapy threshold but TSB > 5 mg/dL above exchange · Follow-up appointment arranged for next transfusion threshold not within 2mg/dL of exchange transfusion threshold · Age < 24 hours · Include NICU attending on calls for day transfusion threshold (e.g. at 72 hours of patients that meet NICU direct admit · Feeding adequately · High suspicion for or lab evidence of age, exchange transfusion threshold 24 criteria. · No concern for significant hemolysis hemolysis (e.g. DAT positive) and TSB 21) Admit to NICU Meets discharge criteria Admit on phototherapy Inpatient Discharge NICU Admission (Off Pathway) ED Management · Give effective phototherapy, keep infant in supine position. · Encourage feeding. The infant should not be removed from bili lights for > 20 mins in any 3 hour period. Use bottle if needed. TSB rising or · DO NOT interrupt phototherapy for patients nearing exchange TSB stable or meeting NICU transfusion threshold or with rapidly rising TSB falling and otherwise admission criteria clinically well · Use maternal EBM for supplemental feeds, when available · Give 20 mL/kg NS bolus then maintenance IV fluids for patients that meet NICU consult criteria · Consider additional labs For questions concerning this pathway, Last Updated: November 2019 contact: [email protected] Next Expected Review: August 2024 © 2019, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Neonatal Jaundice for Infants ≥ 35 Weeks Gestational Age v4.1 Approval & Citation Explanation of Evidence Ratings Summary of Version Changes PHASE II (INPATIENT) Inclusion Criteria · Previously healthy · Age ≤ 14 days · Born at ≥ 35 wks gestational age Exclusion Criteria ! ! · Direct hyperbilirubinemia Rebound TSB Supplemental · Meets NICU Direct Admit Criteria NOT routinely IV Fluids NOT · TSB > 5mg/dL above exchange indicated prior to routinely indicated transfusion threshold discharge · Signs of acute bilirubin encephalopathy · Suspected sepsis or ill-appearing Inpatient Management · Initiate Hyperbilirubinemia (Neonatal) Admit Orders · If direct admit, obtain baseline total serum bilirubin (TSB) · Continue effective phototherapy until TSB at least 3 mg/dL below phototherapy threshold · Encourage feeding. The infant should not be removed from bili lights for > 20 mins in any 3 hour period. Use bottle if needed. · If patient unable to maintain normal temperature in an open crib, place in isolette per Isolette Use Policy & Procedure (for SCH only) · Consider additional labs for patients meeting NICU consult criteria · Run maintenance IV fluids for patients within 2 mg/dL of exchange transfusion threshold or with rapidly rising TSB. Stop IVF once TSB has fallen to at least 2 mg/dL below exchange transfusion threshold and feeding well (e.g. at 72 hours of age, exchange transfusion threshold 24 and TSB less than 22) TSB within 2 mg/dL of exchange transfusion threshold, age <72 hours, or known/suspected hemolysis? No Yes No Subsequent Labs Subsequent Labs · TSB approximately 12 hours after starting · TSB every 4 hours until TSB falling phototherapy (or with routine AM labs) · G6PD (for unexplained hemolysis) · Subsequent checks as clinically indicated Meets Discharge Criteria · Patient off phototherapy and otherwise well · Follow-up appointment arranged for next day · No concern for significant ongoing hemolysis Yes Discharge For questions concerning this pathway, Last Updated: November 2019 contact: [email protected] Next Expected Review: August 2024 © 2019, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Go to Pathophysiology Pg 2 Return to ED Management Return to Inpatient Management Go to Pathophysiology Pg 3 Return to ED Management Return to Inpatient Management Go to Pathophysiology Pg 4 Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Pathophysiology of ABO Incompatibility Almost exclusively O mothers with A or B fetus • A, B mothers make IgM antibodies • O mothers make IgG antibodies • IgM does not cross the placenta; IgG does Less severe than Rh disease • “Distraction” (A & B antigens are widely expressed in various tissues so RBCs are not the only target) • Low A & B surface Ag expression on fetal RBCs = fewer reactive sites Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Guidelines for Initiation of Phototherapy In Hospitalized Infants of 35 or More Weeks’ Gestation These levels are approximations representing a consensus based on limited evidence. [LOE: E (AAP 2004)] AAP. Pediatrics 2004;114(1):297-316 ©2004 by American Academy of Pediatrics Return to ED Management Return to Inpatient Management Guidelines for Exchange Transfusion In Infants 35 or More Weeks’ Gestation These levels are approximations representing a consensus based largely on the goal of keeping TSB levels below those at which kernicterus has been reported. [LOE: E (AAP 2004)] AAP. Pediatrics 2004;114(1):297-316 ©2004 by American Academy of Pediatrics Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Feeding • Encourage feeding. The infant should not be removed from bili lights for > 20 mins in any 3 hour period. Use bottle while remaining under bili lights if needed • Use maternal expressed breast milk for supplemental feeds, when available • Lactation consultation if mom desires to breast feed Rationale: Formula feeds and breastfeeding are equally effective at reducing serum bilirubin during phototherapy. [LOE: moderate quality (NICE 2010)] Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Return to ED Management Return to Inpatient Management Value Analysis: Blood Glucose VALUE ANALYSIS TOOL DIMENSION CARE OPTION A CARE OPTION B PREFERRED OPTION ASSUMPTIONS MADE DESCRIPTION OF CARE TREATMENT OPTION Obtain serum blood Do not routinely obtain glucose on all patients blood glucose levels on admitted with neonatal patients unless jaundice symptomatic OPERATIONAL FACTORS Percent adherence to care (goal 80%) Neutral Neutral NEUTRAL Care delivery team effects Preferred OPTION B BENEFITS / HARMS (QUALITY/OUTCOME) Degree of recovery at discharge Neutral Neutral NEUTRAL Effects on natural history of the disease over equivalent time Neutral Neutral NEUTRAL Potential to cause harm Neutral Neutral NEUTRAL Palatability to patient/family Preferred OPTION B Population-related benefits Neutral Neutral NEUTRAL Threshold for population-related benefits reached COST (Arising from Options A or B) - express as cost per day “ROOM RATE” ($ or time to recovery) Neutral Neutral NEUTRAL “Dx/Rx” costs ($) Preferred OPTION B SAVINGS: $1,333/yr COST (Complications/adverse effects arising from Options A or B)- express as cost per day “ROOM RATE” ($ or time to recovery) Neutral Neutral NEUTRAL “Dx/Rx” costs ($) Neutral Neutral NEUTRAL VALUE ANALYSIS GRID BENEFIT (QUALITY & OUTCOMES) COST A > B A = B A < B Unclear A costs more than B Make value judgement B B Do B and PDSA in 1 year A or B, operational A or B, operational A and B costs are the same A factors may influence B factors may influence choice choice, PDSA in 1 year B costs more than A A A Make value judgement Do A and